OMB Control Number: 1405-0153

Form: DS-5501
ELECTRONIC DIVERSITY VISA ENTRY FORM Expires: 05/31/2011
Estimated Burden: 30 minutes

Part One - Entrant Information

1. Name
a. Last/Family Name b. First Name c. Middle Name

No Last/Family Name No First Name No Middle Name

2. Birth Date
a. Day b. Month c. Year

3. Gender

Male Female
4. City Where You Were Born
(Enter Birth City Only. Do not enter District/County/Province/State)

Birth City Unknown

5. Country Where You Were Born

6. Country of Eligibility for the DV Program

Your country of eligibility will normally be the same as your country of birth. Your country of
eligibility is not related to where you live. If you were born in a country that is not eligible for the
DV program, please go to Explanation of Country of Eligibility {this link will open in a new
window} to see if there is another option available in your case.
Are you claiming eligibility based on the country where you were born?

Yes No
If not, you must enter the country from which you are claiming eligibility.
7. Entrant Photograph
Photographs must be submitted at the time of E-DV entry. Photographs that do not comply with all
specifications, including but not limited to recency of the photos, composition of the photos, and
unacceptable backgrounds are grounds for disqualification of the entire entry. Any manipulation of
photographs that alters the facial characteristics is grounds for disqualification of the entire entry.
See examples on the Photo Validation {this link will open in a new window} page.

Please refer to the Instructions for the 2012 Diversity Immigrant Visa Program (DV-2012) for
technical specifications and compositional specifications for the digital image.

You will use one of the following methods to enter the image into eDV:

• Take a new digital image.

• Use a digital scanner to scan a submitted photograph.

Link to photo instructions/photo validation page {this link will open in a new window}
Photograph File Name

If you know the location in the computer and the name of the file which is storing the photograph,
enter in the box to the left of the 'Browse' button. If you are not sure of the location in the computer
or the name of the file, clicking the 'Browse' button will allow you to look for and choose the file
which is storing the photograph, and after you choose the file its name will appear in the box
above.
8. Mailing Address
8a. In Care Of (optional)

8b. Address Line 1

8c. Address Line 2 (optional)

8d. City/Town

8e. District/County/Province/State

8f. Postal Code/Zip Code No Postal Code/Zip Code

8g. Country
(NOTE: This is the address that will be used to notify you if you are selected.)
9. Country Where You Live Today

10. Phone Number

(optional)
11. E-mail Address
(e.g. johndoe@example.com)
12. What is the highest level of education you have achieved, as of today?
Primary school only University Degree
High School, no degree Some Graduate Level Courses
High School degree Master's Degree
Vocational School Some Doctorate Level Courses
Some University Courses Doctorate Degree

You must have a minimum of a high school diploma reflecting the completion of a full course of
study (vocation schools or equivalency degrees are not acceptable) or be a skilled worker in an
occupation that requires at least two years of training or experience to qualify (visit
http://online.onetcenter.org/ {this link will open in a new window} to see if your occupation
qualifies) for a Diversity Visa.
13. What is your current marital status?
Unmarried
Married
Divorced
Widowed
Legally Separated

Legal separation means that a court has formally declared that you and your spouse are legally
separated. Legal separation means that your spouse would not be eligible to immigrate as your
derivative.
14. Number of Children
(optional)

Children include all biological children, legally adopted children, and stepchildren who are
unmarried and under the age of 21 on the date that you submit your entry. Failure to include all
children or inclusion of children who are not your biological children, legally adopted children,
and stepchildren (regardless of whether they live with you and/or intend to apply for a visa as your
derivative) is grounds for disqualification of the entire entry.

Legal Permanent Residents (LPR) and American Citizens should not be included.
Continue Cancel Entry

PAPERWORK REDUCTION ACT: Public reporting burden for this collection of information is estimated to average 30 minutes per response,
including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documen
required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB cont
number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: A/GIS/D
Room 2400 SA-22, U.S. Department of State, Washington, DC 20522-2202.
CONFIDENTIALITY STATEMENT: AUTHORITIES: The information asked for on this form is requested pursuant to Section 222 of the Immigra
and Nationality Act. Section 222(f) provides that the records of the Department of State and of diplomatic and consular offices of the United St
pertaining to the issuance and refusal of visas or permits to enter the United States shall be considered confidential and shall be used only for t
formulation, amendment, administration, or enforcement of the immigration, nationality, and other laws of the United States. Certified copies o
such records may be made available to a court provided the court certifies that the information contained in such records is needed in a case
pending before the court. PURPOSE: The U.S. Department of State uses the facts you provide on this form primarily to determine your classific
and eligibility for a U.S. immigrant visa. Individuals who fail to submit this form or who do not provide all the requested information may be de
U.S. immigrant visa. Although furnishing this information is voluntary, failure to provide this information may delay or prevent the processing o
case. ROUTINE USES: If you are issued an immigrant visa and are subsequently admitted to the United States as an immigrant, the Departmen
Homeland Security will use the information on this form to issue you a Permanent Resident Card, and, if you so indicate, the Social Security
Administration will use the information to issue a social security number. The information provided may also be released to federal agencies for
enforcement, counterterrorism and homeland security purposes; to Congress and courts within their sphere of jurisdiction; and to other federa
agencies who may need the information to administer or enforce U.S. laws.

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